Using the Internet to provide cognitive behaviour therapy

Article (PDF Available)inBehaviour Research and Therapy 47(3):175-80 · March 2009with1,381 Reads
DOI: 10.1016/j.brat.2009.01.010 · Source: PubMed
A new treatment form has emerged that merges cognitive behaviour therapy with the Internet. By delivering treatment components, mainly in the form of texts presented via web pages, and provide ongoing support using e-mail promising outcomes can be achieved. The literature on this novel form of treatment has grown rapidly over recent years with several controlled trials in the field of anxiety disorders, mood disorders and behavioural medicine. For some of the conditions for which Internet-delivered CBT has been tested, independent replications have shown large effect sizes, for example in the treatment of social anxiety disorder. In some studies, Internet-delivered treatment can achieve similar outcomes as in face-to-face CBT, but the literature thus far is restricted mainly to efficacy trials. This article provides a brief summary of the evidence, comments on the role of the therapist and for which patient and therapist this is suitable. Areas of future research and exploration are identified.
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Invited Essay
Using the Internet to provide cognitive behaviour therapy
Gerhard Andersson
Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linko
ping University, Linko
ping, Sweden
Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institutet, Stockholm, Sweden
article info
Article history:
Received 30 November 2008
Received in revised form
5 January 2009
Accepted 20 January 2009
Guided Internet-delivered treatment
Anxiety disorders
Mood disorders
Therapist input
A new treatment form has emerged that merges cognitive behaviour therapy with the Internet. By
delivering treatment components, mainly in the form of texts presented via web pages, and provide
ongoing support using e-mail promising outcomes can be achieved. The literature on this novel form of
treatment has grown rapidly over recent years with several controlled trials in the field of anxiety
disorders, mood disorders and behavioural medi cine. For some of the conditions for which Internet-
delivered CBT has been tested, independent replications have shown large effect sizes, for example in the
treatment of social anxiety disorder. In some studies, Internet-delivered treatment can achieve similar
outcomes as in face-to-face CBT, but the literature thus far is restricted mainly to efficacy trials. This
article provides a brief summary of the evidence, comments on the role of the therapist and for which
patient and therapist this is suitable. Areas of future research and exploration are identified.
Ó 2009 Elsevier Ltd. All rights reserved.
Defining Internet-delivered interventions can be problematic as
there are different conceptualisations and viewpoints. A first
distinction relates to the Internet itself, as it can be a way to
communicate with a physical person on the other side of the
connection (e.g., e-mail), a way to present information in a more or
less one way direction (information web pages), or a platform for
more interactive programs which do not require any input from
a clinician. Finally, Internet interventions can be a little bit of all
this. In some ways this resembles the problems when trying to
define psychotherapy, even within cognitive behaviour therapy
(CBT), as we are dealing with different techniques and delivery
approaches. All of these may have an impact on the manner in
which the therapy works. For example, the differences between
individual and group CBT can be substantial, and different change
processes could be involved (Morrison, 2001). In our research
program in Sweden we have developed an approach to Internet-
delivered CBT which is distinct in the sense that it involves
therapist contact, albeit minimised, and that it is not heavily
computerised in terms of interactive programmes requiring no
therapist input. According to Marks, Cavanagh, and Gega (20 07),
computerised interventions should delegate at least some therapy
decisions to the computer, but in the approach I will present in this
paper this is not necessarily the case as the Internet very well can
be used without any automatic, computer generated decision
making. When describing our approach Marks et al. referred to the
Swedish model as ‘‘Net-bibliosystem CBT’’, but that does not fully
catch the essence of the approach. In a paper by our group we
instead proposed the following definition of guided Internet-
delivered treatment:
. a therapy that is based on self-help books, guided by an
identified therapist which gives feedback and answers to
questions, with a scheduling that mirrors face-to-face treat-
ment, and which also can include interactive online features
such as queries to obtain passwords in order to get access to
treatment modules (Andersson, Bergstro
m et al., 2008 p. 164)
As seen from this definition we used the term self-help, which
may cause some confusion. In research it is often the case that self-
help refers to treatments that are delivered with minimal input
from a clinician (Watkins & Clum, 2008). That approach is different
from purely self-administered self-help. Guided Internet-delivered
treatment is an approach which combines the advantages of
structured self-help materials, presented in an accessible fashion
via the Internet, with the important role played by an identified
therapist who provide support, encouragement and occasionally
direct therapeutic activities via e-mail (Postel, de Haan, & De Jong,
20 08). As will be seen in this review there are strong reasons to
assume that it is premature to leave out the therapist when moving
to the new format of Internet-delivered CBT. For example, if
Internet delivery is regarded as mainly one way to decrease ther-
apist time, this follows a long-standing tradition in CBT when
Department of Behavioural Sciences and Learning, Linko
ping University, SE-581
83 Linko
ping, Sweden. Tel.: þ46 13 285 840; fax: þ46 13 282 145.
E-mail address:
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Behaviour Research and Therapy 47 (2009) 175–180
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treatments are shortened without compromising the efficacy
(e.g., Clark et al., 1999; O
st, 1997).
The present review will describe and comment on how CBT has
the potential to reach more people by using the Internet. The focus
will not be to describe all studies that have now been conducted
(see Barak, Hen, Boniel-Nissim, & Shapira, 2008), but rather to give
examples of trials and consider questions regarding therapist
factors and dissemination issues. Indeed, systematic reviews of the
literature on Internet-delivered CBT show that moderate to strong
effects are observed at posttreatment (e.g., Cuijpers, van Straten, &
Andersson, 2008a; Spek, Cuijpers et al., 20 07).
Anxiety disorders
Among the first conditions to be systematically studied in self-
help research and later on in research on Internet-delivered CBT are
the anxiety disorders. Many people never seek help or do it after
years of suffering (Clark, 1999).
Panic disorder
More or less simultaneously, two independent research groups
began to investigate if CBT for panic disorder could be delivered via
the Internet. Typically, treatment consists of text materials like in
bibliotherapy, but presented via the Internet and with some
interactive features. Treatment is supported by a therapist with e-
mail or telephone and duration of treatment is often up to
10 weeks. A few smaller trials by the Australian research group
showed promising outcomes (Klein & Richards, 2001; Richards &
Alvarenga, 2002). Later research by the same group, but with larger
samples and improved programs confirmed the early findings
(Klein, Richards & Austin, 2006; Richards, Klein, & Austin, 2006),
and also extended the application by including other providers of
treatment (Shandley et al., 2008). In a recent trial they compared
Internet-delivered and face-to-face treatment and found equiva-
lent outcomes (Kiropoulos et al., 2008). In this latter study,
participants with a primary diagnosis of panic disorder were
randomly assigned to either guided Internet-delivered CBT or to
best practice face-to-face CBT. In other words this was an equiva-
lence trial (Piaggio, Elbourne, Altman, Pocock, & Evans, 2006), as
the authors expected and powered their study assuming equal
outcome. The authors found that 30.4% (14/46) of their panic online
treatment participants reached the criteria of high end-state
functioning, with the corresponding figure in the face-to-face
group being 27.5% (11/40). High end-state was defined as being free
of panic and having a panic disorder clinician severity rating of less
than 2 (on a 0–8 scale).
Our Swedish group has independently conducted similar
research with three controlled trials all showing positive outcomes
(Carlbring, Westling, Ljungstrand, Ekselius, & Andersson, 2001,
Carlbring, Ekselius, & Andersson 2003; Carlbring et al., 2006 ), and
a direct comparison between face-to-face and Internet-delivered
CBT (Carlbring et al., 2005). In the Carlbring et al. (2003) study two
active online treatments were compared (CBT versus applied
relaxation), showing small differences in outcome. While this could
be viewed as an argument for placebo effects in online CBT, we
hesitated to draw that conclusion as applied relaxation following
the protocol of O
st (1987) has been found to generate good
outcome in Swedish panic trials (e.g., O
st & Westling, 1995). In
terms of effect sizes we have generally found high standardised
effect sizes, both for primary panic-related outcomes and
secondary outcomes. For example, in the trial in which we added
brief weekly supportive telephone calls ( Carlbring et al., 2006), the
mean between group effect size across all measures was d ¼ 1.00,
and outcomes were sustained at 9-month follow-up.
A third research group has independently tested Internet-
delivered CBT for panic disorder, again showing that the treatment
concept appears to hold (Schneider
Marks, & Bach-
ofen, 2005). The trial by that group differs in many respects from
the trials conducted by the Australian and Swedish research groups,
as in the outcome measures used. Overall, however the three
independent replications by different research groups all point in
a similar direction. A problem is that most trials have been small
and there are few effectiveness studies showing that the treatment
works in regular health care settings. A recent exception was an
open uncontrolled Swedish trial in which we found that the results
from the efficacy trials were replicated in a psychiatric setting
m et al., 2009).
With all these trials we still need to be cautious as policy makers
and some clinicians immediately infer that Internet delivery is close
to free once the costs for programming have been covered. This is
not the case. For example, the role of support was indirectly showed
by Farvolden et al. (2005) who had a poor outcome and a huge
dropout rate when no guidance was provided and the Internet
program was made freely available.
Social anxiety disorder
Our research group inevitably came across social anxiety
disorder (SAD)/social phobia in our research on panic as we had to
exclude people who did not fulfil the criteria for panic disorder and
mainly had their panic attacks in social situations. At the outset we
first believed that it could not be enough to use a mainly text-based
treatment (albeit with instructions on how self-exposure should be
conducted), and hence we added two live group exposure sessions
in our first study (Andersson, Carlbring et al., 2006). In the
following trial we omitted the live exposures (Carlbring et al.,
2007), which did not affect the outcome. Further trials from our
group corroborate these preliminary findings (e.g., Tillfors et al.,
2008), and between group effect sizes against no treatment
controls ranging between d ¼ .73 to d ¼ .98 for the Liebowitz Social
Anxiety Scale self-report version (Baker, Heinrichs, Kim, & Hof-
mann, 2002) have been reported. Two other research groups have
found similar effects. Titov and coworkers in Australia reported two
trials (Titov, Andrews, Schwencke, Drobny, & Einstein, 2008; Titov,
Andrews, & Schwencke, 2008), with between group effect sizes
above d ¼ .80. Berger, Hohl, and Caspar (2008) in Switzerland have
replicated the findings as well, with the common elements being
a structured CBT program and guidance via Internet.
It is not obvious that Internet-delivered CBT should work for
patients with SAD. It could be argued that we instead reinforce
their avoidance of contact with people. Indeed it has been found
that persons with severe social anxiety disorder do use the Internet
extensively (Erwina, Turk, Heimberg, Frescoa, & Hantula, 2004). On
the other hand, the ’’safe’’ environment in front of the computer
might facilitate the necessary learning phase in CBT, in which the
principles of treatment are described (e.g., rationale). Exposure and
modification of behaviours such as safety behaviours in real life will
however be needed, and are parts of the effective programs. Our
experience so far is that many persons with social anxiety manage
to go out and seek exposure with the guidance of a self-help
programme and an online support person.
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is a debilitating condi-
tion with marked symptoms of avoidance and intrusions that can
have a significant negative impact on the quality of life (Keane &
Barlow, 2002). As with other anxiety disorders shame is often
involved and hence, the prospect of receiving treatment from
G. Andersson / Behaviour Research and Therapy 47 (2009) 175–180176
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a distance can appear appealing. At least four different research
groups have developed Internet treatments for symptoms of
PTSD. First were a Dutch group who developed their own
approach called ‘‘Interapy’’ (Lange, van de Ven, & Schrieken,
20 03). This protocol has been tested in RCTs (e.g., Lange, Rietdijk
et al., 2003), and includes many ingredients involving structured
writing assignments in line with the work by Pennebaker (1993).
Another research group conducted a small controlled study on an
Internet-based self-help program with some therapist support
(Hirai & Clum, 2005). Improvements were observed with above
half of the treated participants showing clinically significant
improvement. A third research group has completed a series of
studies on trauma and grief, focusing on the working alliance, and
found high patient ratings of therapeutic alliance in Internet
treatment, as well as improvements on symptoms measures
(e.g., Knaevelsrud & Maercker, 2007). This group used the same
program as the Lange group (Lange, Rietdijk et al., 2003), and
replicated their findings. Independently, a fourth group have
developed and tested an Internet-based CBT treatment for PTSD
(Litz, Engel, Bryant, & Papa, 2007). In their controlled trial they
had an active control group, which is uncommon in this research
field. The authors reported a between group effect size of d ¼ 0.95
for their overall measure of PTSD symptoms, when considering
treatment completers at 6-month follow-up. Using intent-to-treat
analyses they reported that a significantly greater percentage of
cases in the CBT group no longer met criteria for PTSD at the 6-
month follow-up. With most studies on PTSD pointing in the
same direction, and with independent research groups replicating
the findings, it is important to further test and develop Internet-
based treatment of PTSD.
Mood disorders
Depression represents one of the major challenges for mainte-
nance of public health (Ebmeier, Donaghey, & Steele, 2006). At least
in a mild to moderate form, depression tends to respond well to
most forms of psychotherapy (Cuijpers, van Straten, Andersson, &
van Oppen, 2008b). This includes self-help interventions (Cuijpers,
1997), and several trials on Internet-delivered CBT have been
conducted by different research groups (Andersson, 2006). Our
own experience in using a guided Internet-delivered program in
three controlled trials has been positive. In the published trial we
found a high between group effect size (d ¼ 0.90) for the main
outcome measure (Andersson, Bergstro
m et al., 2005). Equally
promising outcomes have been reported in the Netherlands (Spek,
Nyklicek, et al. 2007). Other groups have found somewhat lower
effects (Christensen, Griffiths, & Jorm,20 04), and even lower effects
and large dropout rates when no support is provided (Christensen,
Griffiths, Mackinnon, & Brittliffe, 2006), but the public health
perspective can still make these low cost alternatives suitable as
early interventions in a stepped-care process. Another group has
also confirmed that Internet-delivered treatment can work but that
some kind of guidance might be needed when targeting depressive
symptoms (Clarke et al., 2002, 2005). It remains to be seen if
depression is particularly sensitive to the need for a therapist, with
at least a few unguided programs showing very weak or non-
existent benefits (e.g., Patten, 2003). It is important to know that
most studies in the field of mood disorders and Internet treatment
have not dealt with diagnosed cases of major depression (e.g.,
O’Kearney, Gibson, Christensen, & Griffiths, 2006), but rather
people with depressive symptoms (Andersson & Cuijpers, 2008).
The literature on Internet-based treatment of major depression and
symptoms is scattered with several research groups
being active. For example, some researchers focus more on
prevention and early intervention (Van Voorhees et al., 2007).
Overall, the evidence is promising and future studies could target
well diagnosed patients as well as maintenance of treatment gains.
Other health problems
There are several other conditions for which guided Internet-
delivered CBT has been tested (Cuijpers et al., 2008a). In our
research group we have conducted controlled trials on tinnitus
(Kaldo et al., 2008), headache (Andersson, Lundstro
m, & Stro
20 03), insomnia (Stro
m, Pettersson, & Andersson, 2004), and
chronic pain (Buhrman, Fa
ltenhag, Stro
m, & Andersson, 2004).
Other targets of Internet-based intervention have included patho-
logical gambling (Carlbring & Smit, 2008), eating disorders (Ljo
son et al., 2007), obesity (Tate, Wing, & Winett, 2001), and stress
management (Zetterqvist, Maanmies, Stro
m, & Andersson, 2003).
Given the number of completed and ongoing trials from different
research groups around the world it is safe to conclude that
Internet-delivered CBT is here to stay. What is less clear is the
format of therapy. For example, the Internet can be used as an
adjunct to existing treatments (Spence, Holmes, March, & Lipp,
20 06), and online assessment procedures are increasingly used in
research and clinic (Andersson, Ritterband, & Carlbring, 2008). It is
now fairly established that psychometric properties of self-report
measures tend to transfer well when the same questionnaires are
administered via the Internet, but that each instrument needs to be
validated for online use (Buchanan, 2003). A likely development in
the near future is that we will see more use of the Internet in
regular clinical practice.
The Internet and the therapist
Emerging evidence across trials clearly suggests that the
computer cannot totally replace human contact, even if it can be
minimised. In fact, we found a correlation of rho ¼ 0.75 (p < 0.005)
between the amount of therapist contact in minutes and the
between group effect size in 15 trials dealing with psychiatric
conditions (Palmqvist, Carlbring, & Andersson, 2007). It is possible
that there is a cut-off point below which smaller effects and more
dropouts are seen. Indeed, this is especially clear in online
depression treatments as little or no therapist contact either via live
meetings, telephone calls or e-mails tend to increase dropout and
reduce effects markedly (Christensen et al., 2006). Spek, Cujpers
et al. (2007) found similar effects of human support in their meta-
A common question is whether Internet treatment can generate
a positive working alliance (Cook & Doyle, 2002). Overall, Internet-
based treatments tend to generate a strong therapeutic alliance
Knaevelsrud & Maercker, 2007),
being strongly associ-
ated with outcome. Some indications of a weaker alliance in
Internet treatments as compared with live CBT have been noted,
albeit not statistically significant (Klein et al., 2006).
Yet another way to investigate if the therapist is important is to
analyse the variance in treatment outcome attributed to the ther-
apist. Using data from three controlled trials on panic disorder,
social phobia and generalised anxiety disorder (total N ¼ 119), with
respect to the individual therapists (N ¼ 8) who gave support
during the treatment period, we have found very small therapist
effects (Almlo
v et al., 2008). This does not rule out the importance
of expertise. First, in many of our Swedish trials we have had
students under supervision as therapists, and it is possible that they
improvise less or adhere more to the protocol as they have little
clinical experience to rely on. Second, the self-help texts used in the
treatments can also reflect clinical experience and empathy, and as
the text material is the same for all trial participants it is rather the
interaction with the therapist and the text that is relevant to
G. Andersson / Behaviour Research and Therapy 47 (2009) 175–180 177
Author's personal copy
consider. For example, if a therapist does not fully understand the
text material, perhaps not having a robust knowledge of CBT, it is
likely that difference in between skilled versus less skilled thera-
pists will be more noticeable.
In sum, there are clear indications that the presence of an online
therapist guiding the patients and providing feedback is important
for adherence and outcome. A therapeutic alliance can also develop
in online treatments, but thus far we cannot say that it matters
much who the therapist is.
For whom is Internet-based treatment suitable?
Some obvious limitations relate to comprehension of text
materials and computer expertise. In many studies, patients who
lack these characteristics are excluded. It does not have to be this
way however, as multimedia presentations (e.g., video and audio
files online), and simplified language can be used to handle these
obstacles. Another limitation relates to comorbidity and the mere
fact that an evidence-based treatment, with its research base
coming from standard individual therapy, does not necessarily
lends itself to the self-help format. On the other hand comorbidity
is not always an obstacle in CBT (e.g., Ramnero
st, 2004), and in
the few studies available on Internet-delivered CBT few consistent
predictors have been identified. In a depression trial we found
a negative correlation between change scores on the main
depression outcome measure and number of previous depression
episodes (Andersson, Bergstro
m, Holla
ndare, Ekselius, & Carlbring,
20 04).
It is also possible that differential predictors of live versus face-
to-face treatment outcomes exist. For example, agoraphobic
avoidance was predictive of outcome in the face-to-face treatment,
but not in the Internet treatment (Andersson, Carlbring, & Grim-
lund, 2008). A self-report screening of personality disorder
(anxious cluster) was associated with the worse outcome for the
Internet treatment, but surprisingly associated with better outcome
in face-to-face treatment. Cognitive capacity as measured by a test
of verbal fluency was not predictive of outcome in the Internet
group, and neither was a rating of treatment credibility. Spek,
Nyklicek, Cuijpers, and Pop (2008) investigated predictors of
outcome of group versus Internet-based CBT for depression. They
found that higher baseline depression scores, female gender, and
low neuroticism predicted better outcome for both groups, but
altruism (as a personality factor) was only related to outcome in the
live group treatment. It is yet premature to draw any conclusions
regarding different predictors, and even less so regarding the
neglected issue of moderators and mediators of outcome in
Internet-delivered CBT. Mediators might include understanding the
written material in the programs, adherence to the homework
conducted, but could also involve other aspects relating more
directly to online behaviours (such as how the website is accessed).
Treatment credibility is another topic that has been investigated
in some trials. For example in one panic trial we compared credi-
bility ratings between live versus Internet CBT (Carlbring et al.,
20 05). Credibility ratings were significantly higher in the face-to-
face treatment condition versus the Internet conditions. A similar
observation was made in a tinnitus trial comparing Internet versus
live group treatment (Kaldo et al., 2008). In terms of prediction we
have found treatment credibility to be predictive of outcome of
Internet-delivered CBT in some studies (e.g., Carlbring et al., 2006),
but not in others (e.g., Carlbring et al., 2001).
Therapists’ attitudes towards Internet treatment are important.
Wangberg, Gammon, and Spitznogle (2007) did a survey on
psychologists in Norway and found that most were rather neutral
regarding the use of the Internet, and a few were very negative.
Moreover, they found that a CBT orientation was associated with
a more positive attitude towards using the Internet than having
a psychodynamic orientation. A similar result was obtained by
Mora, Nevid, and Chaplin (2008), with CBT practitioners being
more positive than psychoanalytically oriented practitioners.
In sum, we have limited knowledge on predictors of outcome
making it hard to state for whom Internet treatment is unsuitable.
Treatment credibility tends to slightly lower than for face-to-face
treatments, and many practitioners of therapy still hesitate to
endorse Internet-based treatments. CBT clinicians however tend to
be more positive.
Future challenges
It is not difficult to identify future challenges regarding Internet-
delivered CBT. Methodological problems are one. High attrition in
some studies is one example. Lack of proper diagnoses in many
. It is also difficult to grasp the content of the self-
help materials used, and the content of treatment programs and
compliance with the treatment could be described better. Another
issue has to do with costs of developing and implementing the
interventions, for example describing the amount of time spent
with each client during the treatment.
A second challenge has to do with dissemination and effec-
tiveness research. While CBT now increasingly has been found to
work in regular clinical settings (Hunsley & Lee, 2007), there are
only a few Internet studies in which the treatment has been
implemented in clinical settings. Some are not really full CBT
treatment programs but should rather be seen ‘‘information’’,
potentially acting as an early step in a stepped-care process. These
programs might very well be feasible from a public health point of
view (Andersson & Cuijpers, 2008). Program such as the ‘‘blue
pages’’ necessitates little if any clinician input (Christensen et al.,
2004), and a large group of people can be given access to the
information content. While clinician input is minimised in the
effective programs, it is still there. From the patient perspective it is
just as time consuming and demanding as live CBT. The main
advantage lies in overcoming distances as clients can get treatment
even if they live far away provided that they have Internet access.
Different treatment formats can be combined. We have tested
combined treatments (e.g., live exposure and Internet treatment) in
some studies. It is possible that future clinicians will stay in touch
with their clients via the Internet (or in some other manner such as
mobile phones) while still having treatment sessions in the clinic. A
potential use of the Internet could be as a tool in relapse prevention,
following an intervention in the clinic. Online maintenance
programs and check-ups could then be used. In fact, most likely the
Internet will be used in some way in more or less all future treat-
ments. Homework assignments could be handled via secure web-
pages. This would be feasible in intensive treatments (for example
with obsessive-compulsive disorder when daily exposure and
response prevention is called for). New technology should not be
automatically seen as a replacement, but rather as a complement to
existing treatment protocols.
Finally, a fourth challenge is to take advantage of the treatment
format. We have recently begun to test tailored treatments using
modified versions of treatment modules from different programs.
For example, a person with anxiety might fulfil the criteria for one
anxiety diagnosis and partly for other diagnoses. In fact, comor-
bidity across the anxiety and mood disorders is more common than
not (Barlow, 2002). This person could be given a tailored program.
This kind of tailored program could consist of psychoeducation,
cognitive restructuring, exposure to both interoceptive (from the
panic program) and social (from the social phobia program) stimuli.
In conclusion, we are only seeing the beginning of Internet-
delivered CBT. It might even be a paradigm shift as CBT clinicians
G. Andersson / Behaviour Research and Therapy 47 (2009) 175–180178
Author's personal copy
are increasingly using text materials in their treatments (Keeley,
Williams, & Shapiro, 2002), and the Internet can be used not only to
present text but also films, and audio files, structured self-assess-
ments, discussion groups, and many other functions. We are now in
a position that we can safely conclude that Internet-delivered CBT
tends to work for a range of problems for at least some of our
patients. Given the lack of trained CBT practitioners and low uptake
of evidence-based treatments (Lovell & Richards, 2000), it would be
inappropriate not to use Internet treatment at least as a comple-
ment to our other treatments.
Co-workers in my research group and former students are
thanked as well as international colleagues in the International
Society for Research on Internet Interventions (http://www.isrii.
org). Finally, my research has been supported by the Swedish
Council for Working and Life Research, Swedish Cancer Foundation,
and the Swedish Research Council.
v, J., Carlbring, P., Ka
llqvist, K., Paxling, B., Cuijpers, P., Andersson, G. (2008).
Therapist effects in guided Internet-delivered CBT for anxiety disorders.
Submitted manuscript.
Andersson, G. (2006). Internet based cognitive behavioral self-help for depression.
Expert Review of Neurotherapeutics, 6, 1637–1642.
Andersson, G., Bergstro
m, J., Buhrman, M., Carlbring, P., Holla
ndare, F., Kaldo, V., et
al. (2008). Development of a new approach to guided self-help via the Internet.
The Swedish experience. Journal of Technology in Human Services, 26, 161–181.
Andersson, G., Bergstro
m, J., Holla
ndare, F., Carlbring, P., Kaldo, V., & Ekselius, L.
(2005). Internet-based self-help for depression: a randomised controlled trial.
British Journal of Psychiatry, 187, 456–461.
Andersson, G., Bergstro
m, J., Holla
ndare, F., Ekselius, L., & Carlbring, P. (2004).
Delivering CBT for mild to moderate depression via the Internet. Predicting
outcome at 6-months follow-up. Verhaltenstherapie, 14, 185–189.
Andersson, G., Carlbring, P., & Grimlund, A . (2008). Predicting treatment outcome in
Internet versus face to face treatment of panic disorder. Computers in Human
Behavior, 24, 1790–1801.
Andersson, G., Carlbring, P., Holmstro
m, A ., Sparthan, E., Furmark, T., Nilsson-
Ihrfelt, E., et al. (2006). Internet-based self-help with therapist feedback and in-
vivo group exposure for social phobia: a randomized controlled trial. Journal of
Consulting and Clinical Psychology, 74, 677–686.
Andersson, G., & Cuijpers, P. (2008). Pros and cons of online cognitive-behavioural
therapy. British Journal of Psychiatry, 193, 270–271.
Andersson, G., Lundstro
m, P., & Stro
m, L. (2003). Internet-based treatment of
headache. Does telephone contact add anything? Headache, 43, 353–361.
Andersson, G., Ritterband, L. M., & Carlbring, P. (2008). A primer for the assessment,
diagnosis and delivery of Internet interventions for (mainly) panic disorder.
Lessons learned from our research groups. Clinical Psychologist, 12, 1–8.
Baker, S. L., Heinrichs, N., Kim, H. J., & Hofmann, S. G. (2002). The Liebowitz Social
Anxiety Scale as a self-report instrument: a preliminary psychometric analysis.
Behaviour Research and Therapy, 40, 701–715.
Barak, A., Hen, L., Boniel-Nissim, M., & Shapira, N. (2008). A comprehensive review
and a meta-analysis of the effectiveness of Internet-based psychotherapeutic
interventions. Journal of Technology in Human Services, 26, 109–160.
Barlow, D. H. (2002). Anxiety and its Disorders. In: The Nature and Treatment of
Anxiety and Panic, Vol. 2. New York: Guilford press.
Berger, T., Hohl, E., & Caspar, F. (2008). Internet-based treatment for social phobia:
a randomized controlled trial. Submitted manuscript .
m, J., Andersson, G., Karlsson, A., Andreewitch, S., Ru
ck, C., Carlbring, P., et al.
(2009). An open study of the effectiveness of Internet treatment for panic disorder
delivered in a psychiatric setting. Nordic Journal of Psychiatry, 63, 44–50.
Buchanan, T. (2003). Internet-based questionnaire assessment: appropriate use in
clinical contexts. Cognitive Behaviour Therapy, 32, 100–109.
Buhrman, M., Fa
ltenhag, S., Stro
m, L., & Andersson, G. (2004). Controlled trial of
Internet-based treatment with telephone support for chronic back pain. Pain,
, 368–377.
Bohman, S., Brunt, S., Buhrman, M., Westling, B. E., Ekselius, L., et al.
(2006). Remote treatment of panic disorder: a randomized trial of Internet-
based cognitive behavioral therapy supplemented with telephone calls. Amer-
ican Journal of Psychiatry, 163,21.
Carlbring, P., Ekselius, L., & Andersson, G. (2003). Treatment of panic disorder via
the Internet: a randomized trial of CBT vs. applied relaxation. Journal of Behavior
Therapy and Experimental Psychiatry, 34, 129–140.
Carlbring, P., Nilsson-Ihrfelt, E., Waara, J., Kollenstam, C., Buhrman, M., Kaldo, V., et
al. (2005). Treatment of panic disorder: live therapy vs. self-help via Internet.
Behaviour Research and Therapy, 43, 1321–1333.
Carlbring, P., Gunnarsdo
ttir, M., Hedensjo
, L., Andersson, G., Ekselius, L., &
Furmark, T. (2007). Treatment of social phobia: randomized trial of internet
delivered cognitive behaviour therapy and telephone support. British Journal of
Psychiatry, 190, 123–128.
Carlbring, P., & Smit, F. (2008). Randomized trial of Internet-delivered self-help with
telephone support for pathological gamblers. Journal of Consulting and Clinical
Psychology, 76, 1090–1094.
Carlbring, P., Westling, B. E., Ljungstrand, P., Ekselius, L., & Andersson, G. (2001).
Treatment of panic disorder via the Internet a randomized trial of a self-help
program. Behavior Therapy, 32, 751–764.
Christensen, H., Griffiths, K. M., & Jorm, A. (20 04). Delivering interventions for
depression by using the internet: randomised controlled trial. British Medical
Journal, 328, 265–268.
Christensen, H., Griffiths, K. M., Mackinnon, A. J., & Brittliffe, K. (2006). Online
randomized trial of brief and full cognitive behaviour therapy for depression.
Psychological Medicine, 36, 1737–1746.
Clark, D. M. (1999). Anxiety disorders: why they persist and how to treat them.
Behaviour Research and Therapy, 37, S5–S27.
Clark, D. M., Salkovskis, P. M., Hackmann, A., Wells, A., Ludgate, J., & Gelder, M.
(1999). Brief cognitive therapy for panic disorder: a randomized controlled trial.
Journal of Consulting and Clinical Psychology, 67, 583–589.
Clarke, G., Eubanks, D., Reid, E., Kelleher, C., O’Connor, E., DeBar, L. L., et al. (2005).
Overcoming depression on the Internet (ODIN) (2): a randomized trial of an
self-help depression skills intervention program with reminders. Journal of
Medical Internet Research, 7,e16.
Clarke, G., Reid, E., Eubanks, D., O’Connor, E., DeBar, L. L., Kelleher, C., et al. (2002).
Overcoming depression on the Internet (ODIN): a randomized controlled trial
of an Internet depression skills intervention program. Journal of Medical Internet
Research, 4,e14.
Cook, J. E., & Doyle, C. (2002). Working alliance in online therapy as compared to
face-to-face therapy: preliminary results. Cyberpsychology & Behavior, 5,
Cuijpers, P. (1997). Bibliotherapy in unipolar depression: a meta-analysis. Journal of
Behavior Therapy and Experimental Psychiatry, 28, 139–147.
Cuijpers, P., van Straten, A.-M., & Andersson, G. (2008a). Internet-administered
cognitive behavior therapy for health problems: a systematic review. Journal of
Behavioral Medicine, 31, 169–177.
Cuijpers, P., van Straten, A., Andersson, G., & van Oppen, P. (2008b). Psychotherapy
for depression in adults: a meta-analysis of comparative outcome studies.
Journal of Consulting and Clinical Psychology, 76, 909–922.
Ebmeier, K. P., Donaghey, C., & Steele, J. D. (2006). Recent developments and current
controversies in depression. Lancet, 367, 153–167.
Erwina, B. A., Turk, C. L., Heimberg, R. G., Frescoa, D. M., & Hantula, D. A. (2004). The
Internet: home to a severe population of individuals with social anxiety
disorder? Journal of Anxiety Disorders, 18, 629–646.
Farvolden, P., Denisoff, E., Selby, P., Bagby, R. M., & Rudy, L. (2005). Usage and
longitudinal effectiveness of a Web-based self-help cognitive behavioral
therapy program for panic disorder. Journal of Medical Internet Research, 7(1), e7.
Hirai, M., & Clum, G. A. (2005). An internet-based self-change program for traumatic
event related fear, distress, and maladaptive coping. Journal of Traumatic Stress,
18, 631–636.
Hunsley, J., & Lee, C. M. (2007). Research-informed benchmarks for psychological
treatments: efficacy studies, effectiveness studies, and beyond. Professional
Psychology: Research and Practice, 38
, 21–33.
S., Widarsson, J., Buhrman, M., Larsen, H. C., & Andersson, G. (2008).
Internet versus group cognitive-behavioral treatment of distress associated
with tinnitus. A randomised controlled trial. Behavior Therapy, 39, 348–359.
Keane, T. M., & Barlow, D. H. (2002). Posttraumatic stress disorder. In D. H. Barlow
(Ed.), Anxiety and its disorders (2 ed.). (pp. 418–453) New York: Guilford Press.
Keeley, H., Williams, C., & Shapiro, D. A. (2002). A United Kingdom survey of
accredited cognitive behaviour therapists’ attitudes towards and use of
structured self-help materials. Behavioural and Cognitive Psychotherapy, 30,
Kiropoulos, L. A., Klein, B., Austin, D. W., Gilson, K., Pier, C., Mitchell, J., et al. (2008).
Is internet-based CBT for panic disorder and agoraphobia as effective as face-to-
face CBT? Journal of Anxiety Disorders, 22, 1273–1284.
Klein, B., & Richards, J. C. (2001). A brief Internet-based treatment for panic
disorder. Behavioural and Cognitive Psychotherapy, 29, 113–117.
Klein, B., Richards, J. C., & Austin, D. W. (2006). Efficacy of internet therapy for panic
disorder. Journal of Behavior Therapy and Experimental Psychiatry, 37, 213–238.
Knaevelsrud, C., & Maercker, A. (2007). Internet-based treatment for PTSD reduces
distress and facilitates the development of a strong therapeutic alliance:
a randomized controlled clinical trial. BMC Psychiatry, 7,13.
Lange, A., Rietdijk, D., Hudcovicova, M., van den Ven, J.-P., Schrieken, B., &
Emmelkamp, P. M. G. (2003). Interapy: a controlled randomized trial of the
standardized treatment of posttraumatic stress through the Internet. Journal of
Consulting and Clinical Psychology, 71, 901–909.
Lange, A., van de Ven, J.-P., & Schrieken, B. (2003). Interapy: treatment of post-
traumatic stress through the Internet. Cognitive Behaviour Therapy, 32, 110–124.
Litz, B. T., Engel, C. C., Bryant, R. A., & Papa, A. (20 07). A randomized, controlled
proof-of-concept trial of an Internet-based, therapist-assisted self-management
treatment for posttraumatic stress disorder. American Journal of Psychiatry, 164,
tsson, B., Lundin, C., Mitsell, K., Carlbring, P., Ramklint, M., & Ghaderi, A. (2007).
Remote treatment of bulimia nervosa and binge eating disorder: a randomized
G. Andersson / Behaviour Research and Therapy 47 (2009) 175–180 179
Author's personal copy
trial of Internet-assisted cognitive behavioural therapy. Behaviour Research and
Therapy, 45(4), 649–661.
Lovell, K., & Richards, D. (20 00). Multiple access points and level of entry (MAPLE):
ensuring choice, accessibility and equity for CBT services. Behavioural and
Cognitive Psychotherapy, 28, 379–391.
Marks, I. M., Cavanagh, K., & Gega, L. (2007). Hands-on help. In: Maudsley mono-
graph, 49. Hove: Psychology Press.
Mora, L., Nevid, J., & Chaplin, W. (2008). Psychologist treatment recommendations
for Internet-based therapeutic interventions. Computers in Human Behavior, 24,
Morrison, N. (2001). Group cognitive therapy: treatment of choice or suboptimal
option? Behavioural and Cognitive Psychotherapy, 29, 311–332.
O’Kearney, R., Gibson, M., Christensen, H., & Griffiths, K. M. (2006). Effects of
a cognitive-behavioural internet program on depression, vulnerability to
depression and stigma in adolescent males: a school-based controlled trial.
Cognitive Behaviour Therapy, 35, 43–54.
st, L.-G. (1987). Applied relaxation: description of a coping technique and review
of controlled studies. Behaviour Research and Therapy, 25, 379–409.
st, L.-G. (1997). Rapid treatments of specific phobias. In G. C. L. Davey (Ed.),
Phobias. A handbook of theory, research and treatment (pp. 227–246). Chichester:
John Wiley and Sons.
st, L.-G., & Westling, B. E. (1995). Applied relaxation vs cognitive behaviour therapy
in the treatment of panic disorder. Behaviour Research and Therapy, 33, 145–158.
Palmqvist, B., Carlbring, P., & Andersson, G. (2007). Internet-delivered treatments with
or without therapist input: does the therapist factor have implications for efficacy
and cost? Expert Review of Pharmacoeconomics & Outcomes Research, 7, 291–297.
Patten, S. B. (2003). Prevention of depressive symptoms through the use of distance
technologies. Psychiatric Services, 54, 396–398.
Pennebaker, J. W. (1993). Putting stress into words: health, linguistic, and thera-
peutic implications. Behaviour Research and Therapy, 31, 539–548.
Piaggio, G., Elbourne, D. R., Altman, D. G., Pocock, S. J., & Evans, S. J. (2006). Reporting of
noninferiority and equivalence randomized trials: an extension of the CONSORT
statement. Journal of the American Medical Association, 295, 1152–1160.
Postel, M. G., de Haan, H. A., & De Jong, C. A. (2008). E-therapy for mental health
problems: a systematic review. Telemedicine and e-Health, 14, 707–714.
, J., & O
st, L. G. (2004). Prediction of outcome in the behavioural treatment
of panic disorder with agoraphobia. Cognitive Behaviour Therapy, 33, 176–180.
Richards, J. C., & Alvarenga, M. E. (2002). Extention and replication of an Internet-based
treatment program for panic disorder. Cognitive Behaviour Therapy, 31,4147.
Richards, J. C., Klein, B., & Austin, D. W. (2006). Internet CBT for panic disorder: does
the inclusion of stress management improve end-state functioning? Clinical
Psychologist, 10, 2–15.
Schneider, A. J., Mataix-Cols, D., Marks, I. M., & Bachofen, M. (2005). Internet-guided
self-help with or without exposure therapy for phobic and panic disorders.
Psychotherapy and Psychosomatics, 74, 154–164.
Shandley, K., Austin, D. W., Klein, B., Pier, C., Schattner, P., Pierce, D., et al. (2008).
Therapist-assisted, Internet-based treatment for panic disorder: can general
practitioners achieve comparable patient outcomes to psychologists? Journal of
Medical Internet Research, 10(2), e14.
Spek, V., Cuijpers, P., Nyklicek, I., Riper, H., Keyzer, J., & Pop, V. (2007). Internet-
based cognitive behaviour therapy for symptoms of depression and anxiety:
a meta-analysis. Psychological Medicine, 37, 319–328.
Spek, V., Nyklicek, I., Cuijpers, P., & Pop, V. (2008). Predictors of outcome of group
and internet-based cognitive behavior therapy. Journal
fective Disorders,
105, 137–145.
Spek, V., Nyklicek, I., Smits, N., Cuijpers, P., Riper, H., Keyzer, J., et al. (2007).
Internet-based cognitive behavioural therapy for subthreshold depression in
people over 50 years old: a randomized controlled clinical trial. Psychological
Medicine, 37, 1797–1806.
Spence, S. H., Holmes, J. M., March, S., & Lipp, O. V. (2006). The feasibility and
outcome of clinic plus internet delivery of cognitive-behavior therapy for
childhood anxiety. Journal of Consulting and Clinical Psychology, 74, 614–621.
m, L., Pettersson, R., & Andersson, G. (2004). Internet-based treatment for
insomnia: a controlled evaluation. Journal of Consulting and Clinical Psychology,
72, 113–120.
Tate, D. F., Wing, R. R., & Winett, R. A. (2001). Using Internet technology to deliver
a behavioral weight loss program. Journal of the American Medical Association,
285, 1172 1177.
Tillfors, M., Carlbring, P., Furmark, T., Lewenhaupt, S., Spak, M., Eriksson, A., et al.
(2008). Treating university students with social phobia and public speaking
fears: Internet delivered self-help with or without live group exposure sessions.
Depression and Anxiety, 25, 708–717.
Titov, N., Andrews, G., & Schwencke, G. (2008). Shyness 2: treating social phobia
online: replication and extension. The Australian and New Zealand Journal of
Psychiatry, 42, 595–605.
Titov, N., Andrews, G., Schwencke, G., Drobny, J., & Einstein, D. (20 08). Shyness 1:
distance treatment of social phobia over the Internet. The Australian and New
Zealand Journal of Psychiatry, 42, 585–594.
Van Voorhees, B. W., Ellis, J. M., Gollan, J. K., Bell, C. C., Stuart, S. S., Fogel, J., et al.
(2007). Development and process evaluation of a primary care Internet-based
intervention to prevent depression in emerging adults. Primary Care Companion
to the Journal of Clinical Psychiatry, 9, 346–355.
Wangberg, S. C., Gammon, D., & Spitznogle, K. (2007). In the eyes of the beholder:
exploring psychologists’ attitudes towards and use of e-therapy in Norway.
Cyberpsychology & Behavior, 10, 418–423.
Watkins, P. L., & Clum, G. A. (Eds.). (2008). Handbook of self-help therapies. New York:
Zetterqvist, K., Maanmies, J., Stro
m, L., & Andersson, G. (2003). Randomized
controlled trial of Internet-based stress management. Cognitive Behaviour
Therapy, 3, 151–160.
G. Andersson / Behaviour Research and Therapy 47 (2009) 175–180180
    • "Internet-delivered CBT seems as a good alternative since it is cheaper, is not time dependent, and requires less therapist involvement [28], and could therefore be given to more patients. Therapist-guided Internet-delivered CBT does not differ from face-to-face treatment with regard to treatment effects [28][29][30] , regardless of the background of the therapist guiding the Internet-delivered CBT [18,[31][32][33]. As concluded by Sharp et al. [34], Internet-delivered CBT might be a means to increase access to psychological treatment to patients with different chronic somatic conditions , although more research is needed to establish the feasibility and efficacy of Internet-delivered CBT for such populations. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Patients with recurrent episodes of non-cardiac chest pain may experience cardiac anxiety and avoidance behavior, leading to increased healthcare utilization. These patients might benefit from help and support to evaluate the perception and management of their chest pain. The purpose of this study was to test the feasibility of a short guided Internet-delivered cognitive behavioural therapy (CBT) program and explore the effects on cardiac anxiety, fear of body sensations, depressive symptoms, and chest pain in patients with non-cardiac chest pain, compared with usual care. Methods A pilot randomized controlled study was conducted. Fifteen patients with non-cardiac chest pain with cardiac anxiety or fear of body sensations, aged 22–76 years, were randomized to intervention (n = 7) or control (n = 8) groups. The four-session CBT program contained psychoeducation, physical activity, and relaxation. The control group received usual care. Data were collected before and after intervention. Results Five of seven patients in the intervention group completed the program, which was perceived as user-friendly with comprehensible language, adequate and varied content, and manageable homework assignments. Being guided and supported, patients were empowered and motivated to be active and complete the program. Patients in both intervention and control groups improved with regard to cardiac anxiety, fear of body sensations, and depressive symptoms, but no significant differences were found between the groups. Conclusions The Internet-delivered CBT program seems feasible for patients with non-cardiac chest pain, but needs to be evaluated in larger groups and with a longer follow-up period. Trial registration NCT02336880. Registered on 8 January 2015.
    Full-text · Article · Dec 2016
    • "Consequently , innovative ways of disseminating effective treatments are needed to close the treatment gap. Internet-delivered interventions have the potential to make evidence-based psychological treatments more accessible to patients, as those interventions are less bound to temporal and geographical barriers [13]. There is a growing body of evidence for internet-delivered cognitive behavior therapy (ICBT) with several reviews showing that ICBT is an effective treatment for adults with various psychological diagnoses [14][15][16]. "
    [Show abstract] [Hide abstract] ABSTRACT: Introduction Childhood Obsessive-Compulsive Disorder (OCD) is a prevalent and impairing condition that can be effectively treated with Cognitive Behavior Therapy (CBT). However, a majority of children and adolescents do not have access to CBT. Internet-delivered CBT (ICBT) has been suggested as a way to increase availability to effective psychological treatments. Yet, the research on ICBT in children and adolescents has been lagging behind significantly both when it comes to quantitative as well as qualitative studies. The aim of the current study was to describe the experience of ICBT in adolescents with OCD. Method Eight adolescents with OCD that had received ICBT were interviewed with qualitative methodology regarding their experiences of the intervention. Data was summarized into thematic categories. Results Two overarching themes were identified, autonomy and support, each consisting of three primary themes (self-efficacy, flexibility, secure self-disclosure and clinician support, parental support, identification/normalization, respectively). Conclusions The experiential hierarchical model that was identified in this study is, in part, transferrable to previous research. In addition, it highlights the need of further study of important process variables of ICBT in young patient populations.
    Full-text · Article · Oct 2016
    • "Thus, there is a tremendous gap between those who might be in need of support and those who actually receive it, and reasons to this gap may be attributed to problems with accessibility of intervention programs and difficulties in identifying and attracting children into these programs [13, 24]. Digital interventions delivered via for instance the Internet or mobile phone applications provide one promising way to reach out and support a larger number of individuals (reviewed in [29][30][31] ). With regards to adolescents and young adults, this seems attractive since they generally have great experience with digital technology and social media. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Depending on the definitions used, between 5 and 20 % of all Swedish children grow up with at least one parent suffering from alcohol problems, while 6 % have at least one parent who has received inpatient psychiatric care, conditions that may affect the children negatively. Nine out of ten Swedish municipalities therefore provide support resources, but less than 2 % of these children are reached by such support. Delivering intervention programs via the Internet is a promising strategy. However, web-based programs targeting this at-risk group of children are scarce. We have previously developed a 1.5-h-long web-based self-help program, Alcohol & Coping, which appears to be effective with regards to adolescents’ own alcohol consumption. However, there is a need for a more intense program, and therefore we adapted Kopstoring, a comprehensive Dutch web-based psycho-educative prevention program, to fit the Swedish context. The purpose of the program, which in Swedish has been called Grubbel, is to strengthen protective factors, such as coping skills and psychological well-being, prevent the development of psychological disorders, and reduce alcohol consumption. Methods/design: The aimof the current study is to evaluate the effectiveness of Grubbel, which targets 15–25-year-olds whose parents have substance use problems and/or mental illness. Specific research questions relate to the participants’ own coping strategies, mental health status and substance use. The study was initiated in the spring of 2016 and uses a two-armed RCT design. Participants will be recruited via social media and also through existing agencies that provide support to this target group. The assessment will consist of a baseline measurement (t0) and three follow-ups after six (t1), 12 (t2), and 24months (t3).Measures include YSR, CES-DC, Ladder of Life, Brief COPE, AUDIT-C, andWHOQOL-BREF. Discussion: Studies have revealed that the majority of children whose parents have substance use or mental health problems are not reached by the existing support. Thus, there is an urgent need to develop, implement, and evaluate novel intervention programs and disseminate successful programs to a broader audience. This study, investigating the effects of a web-based intervention, therefore makes an important contribution to this field of research. Trial registration: ISRCTN10099247. Retrospectively registered on August 31, 2016. Keywords: Child of impaired parents, Children of alcoholics, Mental illness, RCT, Web-based intervention, Digital intervention, Internet, Social media, Chat, Group
    Full-text · Article · Sep 2016
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